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Based on observation and interview, the facility failed to ensure emergency generators were maintained according to NFPA (National Fire Protection Association) standards. This deficiency had the potential to affect patients, staff, and other occupants of the building.

The findings include:

Observation during the Life Safety Code survey on 01/30/18 at 1:15 PM conducted with the Director of Maintenance (DOM), revealed a generator annunciator panel was located in the maintenance office area. However, the generator annunciator panel, which warns of potential problems associated with the emergency generator, must be located at a site which is observable by personnel.

An interview with the DOM on 01/30/18 at 1:15 PM revealed the facility had two (2) generators and two (2) generator annunciator panels. The DOM stated the second panel was located in an electrical room that was not observable by personnel. The DOM stated he was not aware generator annunciator panels were required to be at a work site observable by personnel.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 99 (2012 Edition).

6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6]
6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1]
6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.
[110:5.6.6.2]
6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of all alarm lamps.
6.4.1.1.17.5 A centralized computer system (e.g., building automation system) shall not be permitted to be substituted for the alarm annunciator in 6.4.1.1.17 but shall be permitted to be used to supplement the alarm annunciator.